Caution with Epidural Opioid Use in Sleep Apnea Patients

Abstract Introduction Home sleep apnea testing (HSAT) has largely supplanted diagnostic polysomnography. Primary care (PC) driven HSAT utilization is common especially in rural settings that lack sleep specialist (SS) support. There have been no studies comparing appropriateness of HSAT utilization in veterans managed by SS vs. PC. Methods We use hub and spoke model to manage patients with OSA. SS selects testing for hub and PC utilizes HSAT for spoke patients. Testing is interpreted by SS. Patients referred for HSAT using WatchPAT over 4 months were compared on test failure rate, adherence to AASM guidelines for OSA diagnosis, adherence to HSAT use criteria, and diagnostic success rate (AHI ≥5) in high risk patients (STOPBANG ≥5) without significant comorbidities or HSAT contraindications compared to all comers. Results There were 125 hub and 170 spoke patients included in the analyses. Baseline characteristics were similar between sites (gender, age, BMI, Epworth sleepiness scale, neck size, STOPBANG, pacemaker dependence, and medication use affecting HSAT). Spoke patients had slightly higher prevalence of comorbidities (hypertension, cardiac arrhythmia, heart failure, COPD, stroke, and long acting opioid use). Complete HSAT failure (no data) was 2% and technical failure (monitoring time <4 hours) was 13% at both sites. Unnecessary studies primarily to confirm OSA in those previously diagnosed on therapy seeking to establish care were 3% (hub) and 21% (spoke). HSAT done in patients without significant comorbidities was 77% (hub) and 68% (spoke). Adherence to HSAT use criteria was 74% at both sites. Diagnostic success rate of prespecified and all comers was 65% vs. 60% at hub and 86% vs. 64% at spoke sites. Conclusion Adherence to AASM guidelines and HSAT use criteria was overall fair with low failure rates. Further improving HSAT protocol for SS and PC with the aim to improve diagnostic success rate and minimize unnecessary studies should be pursued. Support

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Chronic Opioid Use is a Risk Factor for the Development of Central Sleep Apnea and Ataxic Breathing

Journal of Clinical Sleep Medicine ◽

10.5664/jcsm.26908 ◽

2007 ◽

Vol 03 (05) ◽

pp. 455-461 ◽

Cited By ~ 226

Author(s):

James M. Walker ◽

Robert J. Farney ◽

Steven M. Rhondeau ◽

Kathleen M Boyle ◽

Karen Valentine ◽

...

Keyword(s):

Risk Factor ◽

Sleep Apnea ◽

Central Sleep Apnea ◽

Opioid Use ◽

Chronic Opioid Use

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Comorbid Insomnia and Sleep Apnea are Associated with Greater Downstream Health Care Utilization and Chronic Opioid Use after Arthroscopic Hip Surgery

January 2018 - Pain Physician ◽

10.36076/ppj/2019.22.e351 ◽

2019 ◽

Vol 4 (22;4) ◽

pp. E351-E360

Author(s):

Daniel I. Rhon

Keyword(s):

Health Care ◽

Sleep Apnea ◽

Sleep Disorders ◽

Orthopaedic Surgery ◽

Medical Utilization ◽

Care Utilization ◽

Opioid Use ◽

Military Health System ◽

Military Health ◽

Chronic Opioid Use

Background: There is a relationship between sleep, pain, and chronic opioid utilization. This has been poorly explored in general, and especially in patients undergoing orthopaedic surgery. Fewer studies have investigated this relationship based on a sleep diagnosis present both before and after surgery. Objectives: To identify the association between insomnia and sleep apnea and downstream opioid use and medical utilization (visits and cost) in the 2 years following arthroscopic hip surgery. Study Design: A retrospective cohort. Setting: The US Military Health System. Methods: This was a consecutive cohort of individuals undergoing hip arthroscopy in the Military Health System (MHS). Medical utilization data were abstracted from the MHS Data Repository between 2003 and 2015, representing 1 year prior and 2 years after surgery for every individual. Sleep disorder diagnoses (insomnia and sleep apnea) were identified using International Classification of Disease codes, and opioid utilization was determined from pharmacy data based on American Hospital Formulary Service codes 280808 and 280812. Sleep disorders present before surgery were used as predictors in multivariate logistic regression, and sleep disorders present after surgery were examined for associations with the outcomes using the Chi-square tests. The dependent variables in both cases were downstream medical utilization (costs, visits, and opioid use). Results: Of 1870 eligible patients (mean age 32.3 years; 44.5% women), 165 (8.8%) had a diagnosis of insomnia before surgery and 333 (17.8%) after surgery; whereas 93 (5.0%) had a diagnosis of apnea before surgery and 268 (14.3%) after surgery. A diagnosis of insomnia before surgery predicted having at least 3+ opioids prescriptions after surgery (adjusted odds ratio, 1.97 [95% confidence interval, 1.39, 2.79]) and greater downstream total medical visits and costs in the 2 years after surgery. However, the number of individuals with a diagnosis of insomnia or apnea after surgery more than doubled, and was significantly associated with chronic opioid use, all-cause medical and all hip-related medical downstream visits and costs in the 2 years after surgery. Limitations: The use of observational data and claims data are only as good as how it was entered. Conclusions: Sleep disorders prior to surgery predicted chronic opioid use and medical utilization after surgery. However, a much higher rate of individuals had sleep apnea and insomnia present after surgery, which were significantly associated with chronic opioid use and greater total and hip-related medical utilization (visits and costs). Screening for sleep disorders prior to surgery may be important, but an even higher rate of sleep disorders may be developed after surgery, and continued screening after surgery may have greater clinical merit. Assessing quality of sleep during perioperative management may provide a unique opportunity to decrease pain and chronic opioid use after surgery. Key words: Pain, opioid use, insomnia, sleep apnea, orthopaedic surgery, military medicine, health care utilization Pain Physician 2019

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The Relationship Between Opioid Use and Obstructive Sleep Apnea: A Systematic Review

10.1164/ajrccm-conference.2020.201.1_meetingabstracts.a2446 ◽

2020 ◽

Author(s):

A. Ahmad ◽

R. Ahmad ◽

M. Meteb ◽

C.M. Ryan ◽

R.S. Leung ◽

...

Keyword(s):

Systematic Review ◽

Obstructive Sleep Apnea ◽

Sleep Apnea ◽

Opioid Use ◽

Obstructive Sleep ◽

The Relationship

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Chronic Opioid Use is a Risk Factor for the Development of Central Sleep Apnea and Ataxic Breathing

Yearbook of Neurology and Neurosurgery ◽

10.1016/s0513-5117(08)79027-6 ◽

2008 ◽

Vol 2008 ◽

pp. 186-187

Author(s):

B. Nolan

Keyword(s):

Risk Factor ◽

Sleep Apnea ◽

Central Sleep Apnea ◽

Opioid Use ◽

Chronic Opioid Use

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825 Central Sleep Apnea and Sinus Bradycardia

SLEEP ◽

10.1093/sleep/zsab072.822 ◽

2021 ◽

Vol 44 (Supplement_2) ◽

pp. A322-A322

Author(s):

Jared Colvert ◽

Glen Greenough

Keyword(s):

Heart Rate ◽

Sleep Apnea ◽

Sinus Bradycardia ◽

Central Sleep Apnea ◽

Respiratory Drive ◽

Central Apnea ◽

Opioid Use ◽

Significant Past Medical History ◽

Obstructive Sleep ◽

Central Apneas

Abstract Introduction Central sleep apnea (CSA) is characterized by a lack of respiratory drive during sleep resulting in repetitive periods of apneas. There are multiple manifestations of CSA as defined by the ICSD3. CSA with Cheyne-Stokes Breathing (CSB) is characterized by a series of crescendo-decrescendo pattern of ventilation followed by central apnea and is often associated with heart failure. Bradyarrythmias have been associated with obstructive sleep apnea (OSA), but an association with central sleep apnea is less clear. Report of case(s) A 76 y/o male with no significant past medical history but with multiple instances of sinus bradycardia on previous EKGs, was referred to sleep medicine for evaluation of snoring, witnessed apneas, and daytime sleepiness. He had no history of CVA, CHF, atrial fibrillation, renal disease, or opioid use. PSG was completed for suspected OSA, and revealed moderate CSA (AHI 10.9 using hypopnea type 1B criteria, CAI 6.1). Central apneas at the latter portion of the study were consistent with a CSA-CSB. Awake heart rate at time of study was 44 bpm. During sleep, his heart rate ranged from 39–89 with a mean of 57 bpm. Due to this unexpected central apnea finding, cardiac evaluation was recommended and echocardiogram revealed a LVEF of 51%, a dilated left atrium, normal left ventricle chamber size, no wall motion abnormalities, and an inability to assess left sided filling pressures. EKG was consistent with sinus bradycardia without AV blocks. Holter monitor revealed sinus rhythm with moderate burden of ectopy. He underwent CPAP titration which revealed an effective CPAP pressure to control obstructive events, but central apneas persisted without CSB pattern. Conclusion In this patient, CSA/CSA-CSB was found in the absence of known risk factors for CSA. Although potentially an early sign of HFpEF related to his longstanding sinus bradycardia, this case raises the question as to whether sinus bradycardia in isolation could decrease cardiac output enough to destabilize ventilation and promote this finding of CSA/CSA-CSB. Support (if any):

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Differences in Epidural and Analgesic Use in Patients with Apparent Stage I Endometrial Cancer Treated by Open versus Laparoscopic Surgery: Results from the Randomised LACE Trial

Minimally Invasive Surgery ◽

10.1155/2013/764329 ◽

2013 ◽

Vol 2013 ◽

pp. 1-5 ◽

Cited By ~ 2

Author(s):

Jannah Baker ◽

Monika Janda ◽

David Belavy ◽

Andreas Obermair

Keyword(s):

Endometrial Cancer ◽

Early Stage ◽

Randomised Trial ◽

Stage I ◽

Postoperative Phase ◽

Opioid Use ◽

Pain Scores ◽

Epidural Opioid ◽

Analgesic Use ◽

Early Stage Endometrial Cancer

Objectives. We compared postoperative analgesic requirements between women with early stage endometrial cancer treated by total abdominal hysterectomy (TAH) or total laparoscopic hysterectomy (TLH).Methods. 760 patients with apparent stage I endometrial cancer were treated in the international, multicentre, prospective randomised trial (LACE) by TAH (n=353) or TLH (n=407) (2005–2010). Epidural, opioid, and nonopioid analgesic requirements were collected until ten months after surgery.Results. Baseline demographics and analgesic use were comparable between treatment arms. TAH patients were more likely to receive epidural analgesia than TLH patients (33% versus 0.5%,P<0.001) during the early postoperative phase. Although opioid use was comparable in the TAH versus TLH groups during postoperative 0–2 days (99.7% versus 98.5%,P=0.09), a significantly higher proportion of TAH patients required opioids 3–5 days (70% versus 22%,P<0.0001), 6–14 days (35% versus 15%,P<0.0001), and 15–60 days (15% versus 9%,P=0.02) after surgery. Mean pain scores were significantly higher in the TAH versus TLH group one (2.48 versus 1.62,P<0.0001) and four weeks (0.89 versus 0.63,P=0.01) following surgery.Conclusion. Treatment of early stage endometrial cancer with TLH is associated with less frequent use of epidural, lower post-operative opioid requirements, and better pain scores than TAH.

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Correlates and consequences of central sleep apnea in a national sample of US veterans

SLEEP ◽

10.1093/sleep/zsy058 ◽

2018 ◽

Vol 41 (9) ◽

Cited By ~ 5

Author(s):

David Ratz ◽

Wyndy Wiitala ◽

M Safwan Badr ◽

Jennifer Burns ◽

Susmita Chowdhuri

Keyword(s):

Sleep Apnea ◽

Hospital Admissions ◽

Comparison Group ◽

Central Sleep Apnea ◽

Prescription Opioid ◽

Cardiovascular Disorders ◽

Health Administration ◽

Opioid Use ◽

Increased Risk ◽

Prescription Opioid Use

AbstractThe prevalence and consequences of central sleep apnea (CSA) in adults are not well described. By utilizing the large Veterans Health Administration (VHA) national administrative databases, we sought to determine the incidence, clinical correlates, and impact of CSA on healthcare utilization in Veterans. Analysis of a retrospective cohort of patients with sleep disorders was performed from outpatient visits and inpatient admissions from fiscal years 2006 through 2012. The CSA group, defined by International Classification of Diseases-9, was compared with a comparison group. The number of newly diagnosed CSA cases increased fivefold during this timeframe; however, the prevalence was highly variable depending on the VHA site. The important predictors of CSA were male gender (odds ratio [OR] = 2.31, 95% confidence interval [CI]: 1.94–2.76, p < 0.0001), heart failure (HF) (OR = 1.78, 95% CI: 1.64–1.92, p < 0.0001), atrial fibrillation (OR = 1.83, 95% CI: 1.69–2.00, p < 0.0001), pulmonary hypertension (OR = 1.38, 95% CI:1.19–1.59, p < 0.0001), stroke (OR = 1.65, 95% CI: 1.50–1.82, p < 0.0001), and chronic prescription opioid use (OR = 1.99, 95% CI: 1.87–2.13, p < 0.0001). Veterans with CSA were at an increased risk for hospital admissions related to cardiovascular disorders compared with the comparison group (incidence rate ratio [IRR] = 1.50, 95% CI: 1.16–1.95, p = 0.002). Additionally, the effect of prior HF on future admissions was greater in the CSA group (IRR: 4.78, 95% CI: 3.87–5.91, p < 0.0001) compared with the comparison group (IRR = 3.32, 95% CI: 3.18–3.47, p < 0.0001). Thus, CSA in veterans is associated with cardiovascular disorders, chronic prescription opioid use, and increased admissions related to the comorbid cardiovascular disorders. Furthermore, there is a need for standardization of diagnostics methods across the VHA to accurately diagnose CSA in high-risk populations.

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